An
Annotated Review of the Evidence Base for Psychosocial and Psychopharmacological
Interventions for Children with Attention-Deficit/Hyperactivity Disorder,
Major Depressive Disorder, Disruptive Behavior Disorders, Anxiety Disorders,
and Posttraumatic Stress Disorder

Interventions must be applicable to school age preadolescent
youth (defined as approximately 612). Studies were included if
they covered this age range, but also included youth who were younger
or older. Interventions that are designed exclusively for adolescents
were not included. The review includes prevention and treatment studies.
Therefore, programs that identify youth who are "at risk"
for developing conduct problems are included. Studies in which ADHD
was the primary diagnostic label were excluded (and are included in
the ADHD section of this report). Studies could be included if they
focused on youth with a definable psychiatric diagnosis (e.g., conduct
disorder, oppositional defiant disorder) or on youth with externalizing
behaviors that may contribute to these types of disorders. The review
includes a number of interventions designed to be delivered via
schools. However, we did not search the education literature for education-specific
interventions (e.g., special education).

Searches were conducted in PsycINFO and Medline electronic
databases, beginning with key words "behavior disorders,"
"conduct disorder," or "disruptive." The query was
limited to (1) refereed journal articles, (2) English language, (3)
1985-1999, (4) school age (612), and (5) empirical studies. This
net was intended to be broad to prevent omission of relevant articles.
This search resulted in 314 articles. The final set was selected by
reading abstracts or articles. Articles were excluded if they: had a
total sample size of less than 30; did not include a comparison group;
did not include youth younger than 13; were focused on program descriptions
or epidemiologic topics; or had insufficient data to examine outcomes
at the completion of intervention. In addition to this search, we also
included older citations from the frequently cited review by Brestan
and Eyberg (1998) of the literature on treating disruptive disorders.
This resulted in a total of 30 included articles.

Brestan and Eybergs review summarized research through
1995. This review has been cited extensively in many recent publications
related to treatment for disruptive behaviors. The current review extends,
rather than duplicates, the Brestan and Eyberg article.

Results from the present review are discussed within five
heuristic categories: parent training; community-based interventions;
clinic-based treatments; prevention programs; and psychopharmacological
treatments. These categories were developed to provide structure in
a field with quite diverse approaches to intervention. In contrast to
the research literature for other disorders in this review, adjunctive
studies examining combined psychosocial and pharmacological interventions
were not found.

Parent training is highlighted because it is a generic
heading that captures both of the "well established" treatments
identified by Brestan and Eyberg. Support seems to be particularly strong
for Webster-Strattons Parents and Children Series. Most of the
research on this intervention has been conducted with parents of youth
in the preschool and early school years.

Community-based interventions primarily include treatments
that are delivered in the child and familys natural ecology and
that focus on meeting the individualized needs of youth and their families.
Multisystemic therapy (MST) has the strongest evidence base within this
section. However, most studies of MST have focused on adolescents, rather
than youth under the age of 13. Various approaches to case management
appear to have positive effects, particularly on treatment-related outcomes
but large direct effects on symptoms have not been found.

Clinic-based interventions included a heterogeneous set
of individual and family-based interventions. Overall, this set of interventions
showed improvements over time for youth. However, differential improvement
between groups was not always significant. This section provides findings
that suggest possible effectiveness of several interventions (e.g.,
day treatment, Problem Solving combined with Parent Management Training,
Family Effectiveness Training). However, the research base is not particularly
strong.

Preventive interventions are unique within this review.
This is in part because the risk factors for disruptive disorders have
been consistently determined, and therefore, prevention programs have
been developed to reduce the probability of later problems in at-risk
youth. All interventions in this section include a multifaceted intervention
that targets the multiple risk factors for the development of disruptive
disorders. An intervention conducted by Tremblay, Vitaro, and colleagues
has the longest followup data, and results look promising into early
adolescence and beyond. Two of the projects included here are recent
additions (e.g., Fast Track, LIFT). Initial outcomes from these projects
look promising, but more time is needed to assess their long-term effects.

Pharmacological interventions are relatively rare with
disruptive disorders (except for youth with comorbid ADHD). Recent studies
suggest potentially positive effects of lithium and methylphenidate
hydrochloride. In both cases, the evidence is not yet extensive.

Overall, interventions for disruptive disorders tend to
focus on the childs behavior and significant others (particularly
parents). There is some evidence for the effectiveness of a variety
of approaches. There is also growing evidence for the effectiveness
of multifaceted prevention programs to prevent development of disorder
in at-risk youth. In the treatment of disruptive disorders, 6- to 12-year-olds
are a relatively understudied population. More attention has been given
to youth who are younger (e.g., preschoolers) or older (e.g., adolescents).
There is a tremendous need for additional research to build upon the
positive interventions listed here and to examine long-term effectiveness.

Included studies based on previous meta-analyses
plus additional search for studies during 1993-95; criteria
for inclusion: prospective design, peer-reviewed journals; 99%
of included studies used a comparison group, 75% used random
assignment

Youth with symptoms of
ODD or CD; included comorbid cases

Not reported in all studies;
typical subject was 9 years old, white, lower-middle income

Not a primary research
article, but included here because it forms the basis for many
contemporary overviews of the state of the field; outcomes appear
to be better with younger children (e.g., preadolescence)

Significant changes, relative
to controls, for families in all treatment groups; few differences
among three interventions, but consistent trend for better outcomes
associated with group discussion videotape modeling

Wiltz & Patterson,
1974

Quasi-experimental design;
parent training vs. Living with Children curriculum vs.
untreated control group (n = 16)

Boys with aggressive behavior

Age: M =
9.8

Gender:
100% boys

Race/Ethnicity: DK

Outcomes available at
end of 5-week treatment; boys in intervention showed decreased
deviant behavior in targeted areas

Small sample size; short-term
outcomes; included because this is listed as one of Brestan and
Eybergs (1998) well established treatments

RCT; treatment team led
by a case manager vs. treatment team without a case manager
(n = 167)

Youth with SED being served
by community mental health center (77% had diagnosis of externalizing
disorder)

Age: 8  17

Gender:
53% boys
47% girls

Race/Ethnicity:
13% African American
77% White

Outcomes available for
1-year period following initiation of treatment; youth with case
manager remained in services longer, received wider array of services,
fewer inpatient days, and more community-based services; symptoms
and functioning did not differ between groups

Control group also served
by multi-agency treatment teams; both groups receiving some version
of coordinated care

Outcomes approximately
2.5 years after program entry; youth in Fostering Individualized
Assistance Program showed fewer placement changes, less amount
of time spent running away from home, and fewer days incarcerated

All findings are only
borderline significant; target group focused on foster children
who had behavior problems (this definition is less strictly oriented
toward disruptive disorders than most other interventions)

Children referred for
placement in Family-Based Treatment (e.g., Treatment Foster Care);
69% had diagnosis of a disruptive behavior disorder

Age: 5  12

Gender:
91% boys
9% girls

Race/Ethnicity:
33% White
67% African American

Outcomes collected every
6 months and 6 months' postdischarge (duration in services varies,
based on needs); improvements in symptoms across time; trend in
favor of Family-Centered Intensive Case Management group, but
not statistically significant

Results very preliminary;
many children still in services; suggests that youth referred
for out-of-home placements can be served equally well at home,
with intensive supports for family

Fraser & Nelson, 1997

Meta-analysis; reviewed
findings on Family Preservation Services

Youth at risk of out-of-home
placement; includes various subgroups (e.g., abuse/neglect, juvenile
delinquents, family reunification)

DK

Outcomes for child welfare
are most relevant in terms of age range (<13); results mixed,
with some evidence (though small) of effects on out-of-home placements;
outcomes for juvenile justice are most relevant in terms of disruptive
disorders; tend to focus on somewhat older youth (1315);
effect sizes range from moderate to large (.48 .92)

Outcomes: end of treatment
and 6 months' posttreatment; some decrease in self-reported alcohol/drug
use at end of treatment in favor of multisystemic therapy; difference
not apparent in urine tests or at 6 months' post-treatment; MST
youth experienced fewer days of out-of-home placement

Many other multisystemic
therapy sites show positive effects; mostly, MST has been conducted
with adolescent populations; smaller effects in this study than
in other MST studies may reflect lower treatment adherence by
clinicians; age range mostly adolescents; included because it
targeted substance use as an outcome

Chart-review of youth
who received psychoanalysis and psychotherapy at Anna Freud Center;
children with disruptive disorders compared to matched sample
of children with emotional disorder (n = 135)

Children with disruptive
disorders

Age: M =
9.0

Gender:
75% boys
25% girls

Race/Ethnicity: DK

33% of disruptive youth
not diagnosable at completion of treatment; improvement was higher
for youth with ODD than with CD; overall, youth with disruptive
disorders improved less than youth with emotional disorders

Treatment most effective
with youth who remained in treatment for full course of psychoanalytic
treatment (e.g., 3 years); 31% terminated treatment within first
year

Grizenko, Papineau, &
Sayegh, 1993; Grizenko, 1997

Quasi-experimental design;
day treatment vs. wait list (n = 30)

Youth with disruptive
disorders who are unable to function in home/school

Age: 5  12

Gender:
77% boys
23% girls

Race/Ethnicity: DK

At 6-month followup, treatment
group more improved than controls on behavior, self-perception,
and school reintegration

Small sample size; 5-year
followup shows some deterioration of outcomes, but still improvements
over baseline

End of treatment and 6-month
followup favored family effectiveness training on family functioning,
children's behavior problems, and childrens self-concept

Intervention designed
to improve family relationships in an effort to strengthen families
and prevent future substance use among youth; designed specifically
for Hispanic families to address intergenerational and intercultural
conflicts

Moderate initial effects
for a broad-based universal and selective prevention program;
effects similar for boys and girls and for different races

Reid, Eddy, Fetrow, &
Stoolmiller, 1999

RCT; 10-week intervention
focusing on parents and students (playground and classroom behavior)
vs. control; based on variety of previous prevention work,
especially that conducted by Oregon Social Learning Center

Initial report on Project
LIFT (Linking the Interests of Families and Teachers); new project,
longer term outcomes not available; attempting to incorporate
a theoretical model of prevention with universal intervention;
not targeted to identified or diagnosed children

Children with elevated
aggression and risk of later conduct problems; selected on the
basis of teacher report

Age:
6 (at selection)
8  9 at intervention

Gender:
100% boys

Race/Ethnicity:
100% French-speaking,
White, Canadians

Outcomes (assessed by
teacher, peer, and self-report) included aggression, delinquency,
and characteristics of friends when students were 10-12 years
old; at age 12, teachers reported less aggressiveness for treatment
group; nonsignificant trends toward less self-reported delinquency
and less disruptive friends

Eligibility based on scoring
above 70th percentile on the Preschool Behavior Questionnaire
during kindergarten; all parents had less than 15 years of schooling